Behaviourally disturbed children are increasingly subjected to a quick fix of drugs. By Ruth Thomson
America's pill-popping culture has extended to very young children, with rising numbers of the under-fives being prescribed psychiatric drugs, raising fears that a similar trend may now be developing in this country.
The extent of the problem emerged in new US research, which found a three-fold rise in the number of two- to four-year-olds being prescribed stimulants, anti-depressants and other drugs for perceived psychiatric problems, such as hyperactivity.
The study, carried out by a team of researchers at Maryland University, analysed prescriptions to more than 200,000 children aged two to four in the five years to 1995. In the largest sample of 150,000 children, it was found that prescriptions of stimulants rose from 4.1 to 12.3 per 1,000 children, while anti-depressant prescriptions increased from 1.4 to 3.2 per 1,000.
Although the numbers of children involved are relatively small, the findings are alarming on several counts. Most of the prescriptions were made 'off label' - that is with no approved guidance from the manufacturers about dosage - because there has only been research into the efficacy of these drugs in treating adults, not very young children.
Some of the drugs were prescribed despite carrying warnings against administering them to very young children. This was the case with the stimulant methylphenidate, the generic name for Ritalin and the drug commonly used to treat attention deficit (hyperactivity) disorder (ADHD), a condition characterised by poor attention and concentration, an inability to follow instructions and compulsive behaviour.
Ritalin accounted for 90 per cent of all stimulants prescribed during the five-year research, yet it carries a warning against using it for children under the age of six and can have a range of side-effects which include increased aggression, sleeplessness and abdominal pain.
The drugs were also prescribed despite virtually no research into the effects they may have on a young child's brain development. Commenting on the findings, Dr Joseph Coyle of Harvard Medical School's psychiatry department notes: 'There is no empirical evidence to support psychotropic drug treatment in very young children and...there are valid concerns that such treatment could have deleterious effects on the developing brain.
'Early childhood is a time of tremendous change for the human brain. Visual processing, language and motor skills are acquired during this sensitive period...at the same time the cerebral metabolic rate peaks between three and four years of age.'
The political fallout from the findings has been substantial. Quick to see the political gain to be had from such an emotive issue so close to the mayoral elections for New York, candidate Hillary Clinton launched a campaign to reduce the number of children receiving these drugs. The White House, in turn, announced plans to investigate the use of Ritalin and to put new Government warning labels on the drugs.
Concern about prescribing trends of psychotropic drugs, particularly Ritalin, has now crossed the Atlantic and raised the question: is the trend the same in this country?
It is hard to establish any increase in prescriptions of psychotropic drugs to children aged five and under because, as in the US, many are used 'off label'.
Small-scale studies and anecdotal evidence, however, suggest that very young children have been prescribed drugs such as Prozac but in very small numbers.
As for Ritalin, the general trend is indisputably upwards, though the vast majority of children taking the drug are of school age. Prescriptions in England rose from about 2,000 to 92,000 in the five years to 1997, while in Scotland new figures from the Scottish Executive show a twentyfold increase, with prescriptions rising from 1,015 to 17,988 in the five years to 1999.
Last year the United Nations International Narcotics Control Board criticised several countries including the UK for overprescribing Ritalin.
The increase in prescriptions, of course, begs the question 'why?' Inevitably, numerous factors have contributed to the trend. In the case of Ritalin prescriptions to school-age children, one factor, on a more positive note, is likely to be a growing awareness and earlier diagnosis of ADHD.
Unfortunately, the US research into under-fives does not attempt to establish the reasons. One factor, the reliability of the diagnoses, is open to question as, notes Dr Coyle, 'the validity and reliability of the diagnoses of attention deficit/hyperactivity disorder, mood disorders, and schizophrenia in very young children have not been demonstrated.'
He believes the mental health services in the US have contributed to the upward trend. Many state health insurance programmes have cut the reimbursement for the evaluation of behavioural disorders in children, limiting a child to seeing one clinical evaluator per day.
As a result the multidisciplinary clinics needed to assess difficult cases have largely disappeared and 'as a consequence,' notes Dr Coyle, 'it appears that behaviourally disturbed children are now increasingly subjected to quick and inexpensive pharmacological fixes'.
While the US health system is radically different from that in the UK, Liberal Democrat health spokesman, and GP, Dr Peter Brand believes that the shortage of child psychiatrists and resulting long waiting lists is contributing to a similar trend here.
Desperate parents facing long waiting lists, he believes, resort to securing drugs on the internet or consulting a private practitioner, who may be more prepared to prescribe drugs. Inappropriate referrals, he argues, have also led to doctors prescribing psychotropic drugs to children as have increased pressure from parents and teachers.
'There is inadequate access to psychotherapeutic support for children so people tend to rely on drugs,' he warns. 'Parents want solutions, schools want solutions, and at times the diagnosis of ADHD may be made too readily and people then start treating the problem with drugs when, in fact, the child and their parents need therapeutic help.'
An Audit Commission report issued last year confirmed long waiting lists: 'Child and mental health services varied in how accessible they were. Waiting times varied and about 10 per cent of trusts could not offer a first appointment for a non-urgent case within six months. Only half of health authorities have arrangements for emergency and 24-hour cover and over one third of trusts felt that they could not respond effectively to young people presenting in a crisis.'
Juliet Buckley who manages the parent information service at mental health charity Young Minds believes the situation is now even worse. 'The waiting lists are horrendous, and waits of a year are quite common,' she says. 'There's a lack of qualified people and where they do exist there are threats to funding. Mental health services are the most underfunded and child mental health is the bottom of the heap.'
The challenge for the NHS is to ensure that children with behavioural problems and their parents receive the treatment and support they need.
Diagnosis can be difficult with any child, but can be particularly hard with the very young, and there is still no professional agreement on certain conditions, particularly ADHD. It has divided the profession, with some doctors refusing to recognise it as a valid condition, and while there is now greater recognition of its existence, there is still controversy over its causes and the efficacy of Ritalin in treating it.
The NHS has already responded to earlier criticisms about the inappropriate use of Ritalin by asking the National Institute for Clinical Excellence to draw up new guidelines for using the drug, to be distributed to practitioners, including GPs, in October. A working party is also drawing up guidelines for the diagnosis and management of ADHD in Scotland.
Ensuring that children and their families receive the time and attention that is necessary to make a proper diagnosis, backed up with proper treatment and support, seems all the more vital in the current climate and in the light of the US research. The NHS is under strain but so too are parents and children.
Child psychotherapist Juliet Brown notes, 'More parents and children are under greater pressure now that both parents are working, so it's more important for the children to comply. They want co-operative children more than ever.'